Scholarship Application

The Lyceum is committed to offering the value of educational enrichment for all children. Limited scholarship funds are available, and are specific to the class/program you are applying for. Not all classes/programs are eligible for scholarships. A copy of your most recent tax return may be required and children must be named as a dependent on the filed return.

Please note: This application is for financial aid to take Lyceum classes. The Lyceum does not provide Scholarships or Financial Aid for non-Lyceum programs/academics.

Parent Name *

Parent Name

First Name

Last Name

Email Address *

Phone

Phone

(###)

###

####

Address *

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Student Name

Student Name

First Name

Last Name

Student Birth Date

Student Birth Date

MM

DD

YYYY

Student Gender

Program you are requesting a scholarship for: *

Child lives with: *

Both Parents

Mother Only

Father Only

Part-time with each parent

Guardian

Have you previously received reduced program fees for Lyceum classes? *

Yes

No

Do you qualify for the free or reduced lunch program at your child's school?

Yes

No

Not Applicable

Does family qualify for any form of public assistance? Check all that apply. *

None

Foodstamps

WIC

SSI

Medical/Medicare

AFDC

Other

Total number of dependent children living at home: *

Ages of dependent children living at home:

Number of dependents on household income:

Total annual household income ($): *

Please remember to include income from salaries, investments, Social Security, unemployment, disability, child's support, TANF, and other sources of income.)

Program Fee:

Program fee for which you are applying for.

$

Amount parent or guardian will pay ($):

Amount you can pay to enroll your child in the program (minimum - 25%)

$

Scholarship amount requested ($):

$

Please indicate any special circumstances that relate to this request:

*

I understand a copy of my most recent tax return may be requested as part of the approval process for my application for scholarship.

*

I certify that the information I have provided herein is true and correct.